Management of severe aortic stenosis in the presence of an 8 mm right coronary stent protrusion.

Management of a protruding coronary stent into the aortic root in patients undergoing evaluation for transcatheter aortic valve replacement can be challenging. We describe a patient treated with stent trimming and surgical aortic valve replacement, highlighting the importance of a multidisciplinary evaluation and selection process in this complex scenario.

Impact of the COVID-19 Pandemic on Infective Endocarditis Management and Outcomes: Analysis of a National Clinical Database.

COVID-19 has widely affected health care delivery, but its impact on the management of infective endocarditis (IE), including valve surgery, is uncertain. We compared the national trends in admissions, demographics, and outcomes of IE before and after COVID-19 onset, using a national sample of IE admissions between 2016 and 2022 from the Vizient Clinical Database. The pre-COVID-19 and post-COVID-19 time periods were separated by the start of the second quarter of 2020, the time during which the COVID-19 pandemic was declared. For all admissions and for admissions involving valve surgery, pre-COVID-19 versus post-COVID-19 baseline characteristics and outcomes were compared using 2-sample t tests or chi-square tests. Propensity score-matched cohorts were similarly compared. Before COVID-19, there were 82,867 overall and 11,337 valve-related surgical admissions, and after COVID-19, there were 45,672 overall and 6,322 valve-related surgical admissions. In the matched analysis for all admissions, the in-hospital mortality increased from 11.4% to 12.4% after COVID-19 onset (p <0.001); in-hospital stroke (4.9% vs 6.0%, p <0.001), myocardial infarction (1.3% vs 1.4%, p = 0.03), and aspiration pneumonia (1.8% vs 2.4%, p <0.001) also increased, whereas other complications remained stable. In the matched analysis of surgical admissions, there was decreased in-hospital mortality (7.7% vs 6.7%, p = 0.03) and intensive care unit stay (8.5 ± 12.5 vs 8.0 ± 12.6 days, p = 0.04); other outcomes remained stable. In conclusion, patients admitted with IE after COVID-19 were more medically complex with worsened outcomes and mortality, whereas patients who underwent valve surgery had stable outcomes and improved mortality despite the pandemic.

Integrated cardiothoracic surgery match: Trends among applicants compared with other surgical subspecialties.

OBJECTIVE: The objective of this study was to evaluate trends, qualifications, race/ethnicity, and gender of applicants to integrated cardiothoracic (CT I-6) residency programs and compare them with other competitive surgical subspecialties. METHODS: Data were collected from the National Residency Matching Program, Electronic Residency Application Service, and Association of American Medical Colleges for thoracic surgery, orthopedic surgery, neurological surgery, otolaryngology (ENT), plastic surgery, and vascular surgery for 2010 t0 2020. Applicant gender, race/ethnicity, Alpha Omega Alpha (AOA) membership, United States Medical Licensing Examination scores, research productivity, and graduation from a top-40 medical school were analyzed. RESULTS: From 2010 to 2020, CT I-6 experienced growth in postgraduate year 1 positions (280.0%), total applicants (62.2%), and US senior applicants (59.2%). No growth in CT I-6 positions (38) or programs (29) occurred from 2016 to 2020. CT I-6 had the lowest match rates among total applicants (31.7%) and US seniors (41.0%) in 2020. CT I-6 had fewer female applicants compared with ENT (P < .001) and plastic surgery (P < .001), but more than orthopedic surgery (P < .001). Although most CT I-6 US applicants self-identified as White (75.0%), there were more Asian applicants compared with applicants for orthopedic surgery (P < .001), ENT (P < .001), plastic surgery (P < .001), and neurological surgery (P < .01). Matched applicants averaged the highest Step 2-Clinical Knowledge scores (255.1), AOA membership (48.5%), and graduation rates from top-40 medical schools (54.5%). CONCLUSIONS: Despite tremendous growth in positions, CT I-6 has consistently been the most difficult surgical subspecialty to match. CT I-6 has recently attracted an increasingly diverse applicant pool. For the 2019 to 2020 National Residency Matching Program Match Cycle, successful applicants had the highest Step 2-Clinical Knowledge scores, AOA membership rates, and graduation rates from a top-40 medical school among all surgical subspecialties examined.

Mitral Valve Replacement With Sapien 3 Transcatheter Valve in Severe Mitral Annular Calcification.

Transcatheter valve implantation in the mitral position with severe calcific mitral stenosis has been described in patients who are at an increased risk for conventional mitral valve surgical procedures. We report the direct deployment of the Sapien 3 valve in the mitral position with severe mitral annular calcification through a sternotomy in an arrested heart in two cases.

Long-term survival for patients with metabolic syndrome after bioprosthetic or mechanical valve replacement.

BACKGROUND: Metabolic diseases are thought to negatively impact the long-term survival of cardiac patients and have been shown to be associated with reduced durability of bioprosthetic heart valves. The purpose of this study is to determine whether long-term survival of post-valve replacement patients is affected by the presence of metabolic disease, and whether choice of tissue versus mechanical prosthesis impacts survival. METHODS: A retrospective review was conducted of all isolated valve replacements performed between 2002 and 2011 from the STS adult cardiac database of Emory Healthcare Hospitals. A total of 1,222 cases were reviewed, of which 909 patients had AVR (661 tissue, 248 mechanical), and 313 MVR (190 tissue, 123 mechanical). Cardiometabolic syndrome (CMS), in accordance with the World Health Organization (WHO) definition, was present in 242 of 1,222 (19.8%) cases in entire cohort, 203 of 909 (22.3%) in AVR, and 39 of 313 (12.5%) in MVR. Cox proportional hazard regression analysis was used to calculate long-term survival after adjusting for propensity score (PS), Society of Thoracic Surgeons Predicted Risk of Mortality (STS PROM), and direct covariates for valve and implant type and stratifying by CMS. RESULTS: In PS adjusted AVR, patients with CMS risk factors had worse survival compared to metabolic risk-free patients (AHR = 3.47), as was the case for MVR (AHR = 4.06). Tissue MVR patients with CMS had higher hazard of death compared to patients with no diabetes and no metabolic risk factors after adjusting for PROM (AHR = 3.33) and direct covariates (AHR = 3.91). CONCLUSIONS: Metabolic diseases negatively impact long-term survival of aortic and mitral valve replacement (MVR) patients. Tissue prostheses are associated with worse long-term survival following MVR.

Outcomes of off-pump versus on-pump coronary artery bypass grafting: Impact of preoperative risk.

BACKGROUND: It is unknown whether purported benefits of off-pump coronary artery bypass grafting are patient-specific within the Society of Thoracic Surgeons National Cardiac Database or dependent on center volume or operating surgeon. METHODS: The Society of Thoracic Surgeons National Cardiac Database was queried for all patients undergoing nonemergency, isolated coronary artery bypass between January 1, 2005, and December 31, 2010, who had Predicted Risk of Mortality scores and participant/surgeon identifiers. Of these 876,081 patients ("all sites"), 210,469 underwent surgery at participant sites that had performed more than 300 off-pump and 300 on-pump coronary artery bypass operations during the 6-year study period ("high-volume sites"). Operative mortality, stroke, acute renal failure, mortality or morbidity, and prolonged postoperative length of stay were analyzed with conditional logistic models for all sites and for high-volume sites, stratified by participant center and surgeon, and adjusted for 30 variables that comprise the Society of Thoracic Surgeons coronary artery bypass grafting risk models. RESULTS: Off-pump coronary artery bypass was associated with a significant reduction in risk of death, stroke, acute renal failure, mortality or morbidity, and postoperative length of stay compared with on-pump coronary artery bypass after adjustment for 30 patient risk factors in the overall sample. This held true within high-volume centers. In the overall sample, there was a significant (P < .05) interaction between off-pump coronary artery bypass and Predicted Risk of Mortality for death, stroke, acute renal failure, and mortality or morbidity. CONCLUSIONS: Off-pump coronary artery bypass was associated with reduced adverse events compared with on-pump coronary artery bypass after adjustment for 30 patient risk factors and center and surgeon identity. Patients with higher Predicted Risk of Mortality scores had the largest apparent benefit.

Off-pump coronary artery bypass grafting--the current state.

The optimal strategy for coronary revascularization remains controversial. Currently, most surgical revascularizations are performed with the use of cardiopulmonary bypass (ONCAB), yet over the past 20 years off-pump coronary artery bypass grafting (OPCAB) has been increasingly used because of the increased awareness of the deleterious effects of cardiopulmonary bypass (CPB) and aortic manipulation. Small, prospective, randomized controlled trials have lacked sufficient sample size to demonstrate differences in early and long-term outcomes. Larger observational studies that are better powered to statistically compare outcomes have shown more favorable in-hospital outcomes and equivalent long-term outcomes with OPCAB and ONCAB. The benefits of OPCAB techniques may be more apparent for patients at high risk for complications associated with CPB and aortic manipulation. Recent studies have demonstrated improved outcomes in higher-risk patients undergoing OPCAB, as well as improved neurological outcomes. The purpose of this review is to outline the recent literature comparing OPCAB with ONCAB, and to demonstrate efficacy of OPCAB as a useful technique for coronary revascularization.

Esophageal stenting for malignant and benign disease: 133 cases on a thoracic surgical service.

BACKGROUND: Esophageal stenting is increasingly being utilized to treat a variety of benign and malignant esophageal conditions. The aim of our study was to review our experience with self-expanding metal, plastic, and hybrid stents in the treatment of esophageal disease on a thoracic surgical service. METHODS: The study population consisted of 126 patients undergoing placement of 133 stents at a single institution from 2000 to 2008. Data were reviewed retrospectively for patient characteristics, indications, complications, reinterventions, and efficacy. RESULTS: Most stents were placed for palliation of dysphagia due to advanced esophageal cancer (90 of 133; 68%) or extrinsic compression from lung cancer (13 of 133; 9.8%). A total of 123 self-expanding metal stents (SEMS), 7 self-expanding plastic stents (SEPS), and 3 hybrid stents were placed. Of the SEMS, 57 were uncovered and 66 were covered. Malignant obstruction was typically palliated with SEMS, while covered stents were chosen for perforations or anastomotic leaks. The median length of stay was 1 day. Complications occurred in 38.3% of stent placements, with a single perioperative mortality resulting from massive hemorrhage on postoperative day 4. Most complications resulted from stent impaction (12.8%), migration (9.7%), or tumor ingrowth (5.3%). Tumor ingrowth was uncommon with uncovered stents (2 of 57; 3.5%). Stent migration was common with SEPS (4 of 7; 57%), or hybrid stents (2 of 3; 67%). Survival was short in patients with underlying malignancy (median 104 days for esophageal cancer and 48 days for lung cancer), with 20% of patients surviving less than 1 month. CONCLUSIONS: Esophageal stent placement is safe and reliable. The goals of therapy are typically met with a single intervention. The majority of patients require no further interventions, though life expectancy often is short and patient selection may be difficult. Most complications are due to stent obstruction, though stent migration is an issue particularly with SEPS and hybrid stents. Esophageal surgeons should be adept at stent placement.

Surgical resection for locoregional esophageal cancer is underutilized in the United States.

BACKGROUND: Although esophagectomy provides the highest probability of cure in patients with esophageal cancer, many candidates are never referred for surgery. We hypothesized that esophagectomy for esophageal cancer is underused, and we assessed the prevalence of resection in national, state, and local cancer data registries. STUDY DESIGN: Clinical stage, surgical and nonsurgical treatments, age, and race of patients with cancer of the esophagus were identified from the Surveillance, Epidemiology and End Results (SEER) registry (1988 to 2004), the Healthcare Association of NY State registry (HANYS 2007), and a single referral center (2000 to 2007). SEER identified a total of 25,306 patients with esophageal cancer (average age 65.0 years, male-to-female ratio 3:1). HANYS identified 1,012 cases of esophageal cancer (average age 67 years, M:F ratio 3:1); stage was not available from NY State registry data. A single referral center identified 385 patients (48 per year; average age 67 years, M:F 3:1). For SEER data, logistic regression was used to examine determinants of esophageal resection; variables tested included age, race, and gender. RESULTS: Surgical exploration was performed in 29% of the total and only 44.2% of potentially resectable patients. Esophageal resection was performed in 44% of estimated cancer patients in NY State. By comparison, 64% of patients at a specialized referral center underwent surgical exploration, 96% of whom had resection. SEER resection rates for esophageal cancer did not change between 1988 and 2004. Males were more likely to receive operative treatment. Nonwhites were less likely to undergo surgery than whites (odds ratio 0.45, p < 0.001). CONCLUSIONS: Surgical therapy for locoregional esophageal cancer is likely underused. Racial variations in esophagectomy are significant. Referral to specialized centers may result in an increase in patients considered for surgical therapy.

Are endoscopic therapies appropriate for superficial submucosal esophageal adenocarcinoma? An analysis of esophagectomy specimens.

BACKGROUND: Endoscopic resection and ablation have advanced the treatment of intramucosal esophageal adenocarcinoma and have been promoted as definitive therapy for selected superficial submucosal tumors. Controversy exists regarding the prevalence of nodal metastases at various depths of mucosal and submucosal invasion. Our aim was to clarify this prevalence and identify predictors of nodal spread. STUDY DESIGN: An expert gastrointestinal pathologist retrospectively reviewed 54 T1 adenocarcinomas from 258 esophagectomy specimens (2000 to 2008). Tumors were classified as intramucosal or submucosal, the latter being subclassified as SM1 (upper third), SM2 (middle third), or SM3 (lower third) based on the depth of tumor invasion. The depth of invasion was correlated with the prevalence of positive nodes. Fisher's exact test and univariate and multivariate logistic regression were used to identify variables predicting nodal disease. RESULTS: Nodal metastases were present in 0% (0 of 25) of intramucosal, 21% (3 of 14) of SM1, 36% (4 of 11) of SM2, and 50% (2 of 4) of SM3 tumors. The differences were significant between intramucosal and submucosal tumors (p < 0.0001), although not between the various subclassifications of submucosal tumors (p = 0.503). Univariate logistic regression identified poor differentiation (p = 0.024), lymphovascular invasion (p = 0.049), and number of harvested lymph nodes (p = 0.037) as significantly correlated with nodal disease. Multivariate logistic regression did not identify any of the tested variables as independent predictors of the prevalence of positive lymph nodes. CONCLUSIONS: All depths of submucosal invasion of esophageal adenocarcinoma were associated with an unacceptably high prevalence of nodal metastases and a marked increase relative to intramucosal cancer. Accurate predictors of nodal spread, independent of tumor depth, are currently lacking and will be necessary before recommending endoscopic resection with or without concomitant ablation as curative treatment for even superficial submucosal neoplasia.

Should elective repair of intrathoracic stomach be encouraged?

BACKGROUND: Given our aging population, patients with an intrathoracic stomach are an increasing clinical problem. The timing of repair remains controversial, and most reports do not delineate morbidity of emergent presentation. The aim of the study was to compare the morbidity and mortality of elective and emergent repair. METHODS: Study population consisted of 127 patients retrospectively reviewed undergoing repair of intrathoracic stomach from 2000 to 2006. Repair was elective in 104 and emergent in 23 patients. Outcome measures included postoperative morbidity and mortality. RESULTS: Patients presenting acutely were older (79 vs. 65 years, p < 0.0001) and had higher prevalence of at least one cardiopulmonary comorbidity (57% vs. 21%, p = 0.0014). They suffered greater mortality (22% vs. 1%, p = 0.0007), major (30% vs. 3%, p = 0.0003), and minor (43% vs. 19%, p = 0.0269) complications compared to elective repair. On multivariate analysis, emergent repair was a predictor of in-hospital mortality, major complications, readmission to intensive care unit, return to operating room, and length of stay. CONCLUSION: Emergent surgical repair of intrathoracic stomach was associated with markedly higher mortality and morbidity than elective repair. Although patients undergoing urgent surgery were older and had more comorbidities than those having an elective procedure, these data suggest that elective repair should be considered in patients with suitable surgical risk.

A population-based analysis of emergent vs. elective hospital admissions for an intrathoracic stomach.

BACKGROUND: Large-scale, population-based analyses of the demographics, management, and healthcare resource utilization of patients with an intrathoracic stomach are largely unknown, an issue which has become more important with the aging of the population. Our objective was to understand the magnitude of the problem and to assess clinical outcomes and hospital costs in elective and emergent admissions of patients with an intrathoracic stomach in a large population-based study. METHODS: The New York Statewide Planning and Research Cooperative System (SPARCS) administrative database was queried for primary ICD-9-CM codes 553.3 and 552.3 in patients 18 years or older; 4858 hospital admissions were identified over a 5-year period (2002-2006). Database variables included age, gender, race, type of admission, operative intervention, in-hospital mortality, length of stay, and cost. RESULTS: Approximately 1000 patients are admitted to the hospital each year with primary diagnosis of intrathoracic stomach, an estimated 52 per 1 million of the population in New York State. Over half of those (53%) were emergent admissions. Interestingly, the majority of emergent admissions (66%) were discharged before any surgical intervention. Patients admitted emergently were older (68.0 vs. 62.1 years, p < 0.0001) and more likely African-American (12% vs. 6%, p < 0.0001). Compared to elective admissions, emergent admissions had higher mortality (2.7% vs. 1.2%, p < 0.001), longer length of stay (LOS) (7.3 vs. 4.9 days, p < 0.0001), and higher cost ($28,484 vs. $24,069, p < 0.001). Among patients who underwent surgery, emergent admissions had higher mortality (5.1% vs. 1.1%, p < 0.0001), greater LOS (13.1 vs. 4.9 days, p < 0.0001), and higher costs ($55,460 vs. $24,760, p < 0.0001). Multivariate regression analysis demonstrated age, emergent presentation, and operative admission as independent predictors for hospital mortality, LOS, and cost (p < 0.0001). CONCLUSIONS: Strikingly, more than half of admissions for intrathoracic stomach were emergent. Emergent admissions had higher mortality, longer LOS, and higher cost than elective admissions. These data support consideration of early elective repair.

Does the value of PET-CT extend beyond pretreatment staging? An analysis of survival in surgical patients with esophageal cancer.

BACKGROUND: Studies of positron emission tomography (PET) have focused mainly on tumor staging. The role of PET in predicting survival has received less attention. We sought to assess the relationship of pretreatment maximum standard uptake value (SUV(max)) to survival in surgical patients with esophageal cancer. METHODS: The study consisted of 72 esophagectomy patients (60 with adenocarcinoma) undergoing resection between July 2005 and April 2009. PET combined with computed tomography (PET-CT) was performed at a single center, and SUV(max) was recorded prior to any therapy. Survival was assessed at a median follow-up of 19 months. RESULTS: The median SUV(max) was 6.25. A receiver operating characteristic curve identified SUV(max) 4.5 to optimally discriminate survival. Patients with low SUV(max) (<4.5) had significantly (p = 0.0003) better survival than those with high SUV(max) (>or=4.5). Stage 3 patients with low SUV(max) had significantly better survival (p = 0.0069) than those with high SUV(max). Likewise, N1 disease patients with low SUV(max) had significantly better survival (p = 0.008) than those with high SUV(max). Multivariate analysis identified SUV(max) to be an independent predictor of survival (p = 0.0021). CONCLUSION: Pretreatment PET-CT SUV(max) independently predicts survival in patients with esophageal carcinoma undergoing resection. SUV(max) may be a valuable marker of tumor biology that could potentially be exploited for prognostic and therapeutic purposes.

Association of kyphosis and spinal skeletal abnormalities with intrathoracic stomach: a link toward understanding its pathogenesis.

BACKGROUND: Modern-day concepts about the pathogenesis of an intrathoracic stomach include crural diaphragm muscular deterioration, loss of phrenoesophageal ligament integrity, and presence of abdominothoracic pressure gradients. The role of spinal abnormalities has received little attention. Based on clinical observation, we hypothesized that kyphosis and other spinal diseases are components of the pathophysiology of an intrathoracic stomach. STUDY DESIGN: The study population consisted of 98 patients (men, n = 22; women, n = 76; mean age 69.4 years) undergoing operations for type III or IV hiatal hernia with an intrathoracic stomach. Twenty-four age- and gender-matched control patients without hiatal hernia undergoing pulmonary or pleural procedures were used for comparison. Chest radiographs were assessed for spinal abnormalities, including degree of kyphosis, measured from superior T4 to inferior T12 (modified Cobb method), spinal fractures, osteoporosis, and scoliosis. Statistical analyses included two-sample t-test and Fisher's exact test. RESULTS: Patients with intrathoracic stomach had a greater degree of kyphosis than control patients (Cobb angle, 50.2 degrees versus 39.7 degrees; p < 0.001). This difference was most pronounced in women (Cobb angle, 51.7 degrees versus 40.4 degrees; p < 0.001), although the difference in men was not significant (Cobb angle, 45.0 degrees versus 38.1 degrees; p = 0.25). Patients with an intrathoracic stomach had significantly more vertebral fractures (37 of 98 [38%] versus 3 of 24 [13%]; p < 0.05). There was no difference in prevalence of degenerative changes (51 of 98 [52%], versus 13 of 24 [54%]), osteopenia (30 of 98 [31%] versus 6 of 24 [25%]), and scoliosis (27 of 98 [28%] versus 6 of 24 [25%]). CONCLUSION: Patients with an intrathoracic stomach have a higher degree of kyphosis and more vertebral fractures than age- and gender-matched controls. These data suggest that change in spinal curvature can be important in the pathogenesis of the intrathoracic stomach, a growing problem of our aging population.

A new era in esophageal diagnostics: the image-based paradigm of high-resolution manometry.

BACKGROUND: The development of high-resolution (HRM) catheters and software displays of manometric recordings in color-coded pressure plots has changed the diagnostic assessment of esophageal disease. HRM may offer advantages over conventional methods, including improved identification of motility disorders, hiatal hernia, and outflow obstruction, and ease interpretation. STUDY DESIGN: HRM studies were obtained in 50 healthy volunteers and 106 patients. HRM was performed using a 36-channel catheter, with sensors spaced at 1-cm intervals. Manometric findings were classified into abnormalities of the gastroesophageal barrier and those of the esophageal body and validated by comparison with endoscopic and radiographic diagnostic methods. RESULTS: The mean time for HRM was significantly lower than that for a conventional method (8.1versus 24.4 minutes; p < 0.0001). A structurally defective lower esophageal sphincter (LES) was present in 53 (57.3%) patients, a hypertensive LES in 6 (7.8%), and impaired LES relaxation in 17 patients (16.7%). Validating the LES findings, 86.3% (44 of 51) of patients with a defective sphincter by HRM had radiographic or endoscopic evidence of a hiatal hernia, and 80% (41 of 51) had a positive pH study, endoscopic erosive esophagitis, or Barrett's esophagus. Evidence of a hiatal hernia by HRM was seen in 33 (56%) patients; a hiatal hernia was seen in 91% (30 of 33) of these on endoscopy and 81% (17 of 21) on barium swallow. Fifty-eight patients (54.7%) had an abnormal body motility. CONCLUSIONS: HRM studies are shorter than those using conventional methods. Interpretation is image based, and correlation with objective endoscopic and physiologic findings confirms the accuracy of interpretation. The introduction of HRM is a significant advance in the outpatient evaluation of esophageal function.